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POLICYHOLDER NOTICE <br />YOUR RIGHT TO RATING AND DIVIDEND INFORMATION <br />Information Available to You <br />A. Information Available from Us - Trumbull Insurance Company <br />(1) General questions regarding your policy should be directed to your Hartford Agent or <br />Trumbull Insurance Company <br />3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />Telephone: (877) 853-2582 <br />www.thehartford.com <br />(2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon <br />payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the <br />basis of the dividend calculation. The explanation will be in clear, understandable language and will <br />express the dividend as a dollar amount and as a percentage of the earned premium for the policy year <br />on which the dividend is calculated. <br />(3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled <br />to receive information in our claim files that affects your premium. Copies of documents will be supplied at <br />your expense during reasonable business hours. <br />For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical <br />purposes eighteen months after the policy becomes effective and will report those estimates to the <br />Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after <br />the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve- <br />month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled <br />claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by <br />the WCIRB to compute your experience modification if you are eligible for experience rating. <br />B. Information Available from the Workers' Compensation Insurance Rating Bureau of California <br />(1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated <br />statistical agent. As such, the WCIRB is responsible for administering the California Workers' <br />Compensation Uniform Statistical Reporting Plan-1995 (USRP) and the California Workers' <br />Compensation Experience Rating Plan-1995 (ERP). WCIRB contact information is: WCIRB, 1221 <br />Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 <br />(fax); and customerservice(aDwcirb.com (email). The regulations contained in the USRP and ERP are <br />available for public viewing through the WCIRB's website at wcirb.com. <br />(2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written <br />request, you are entitled to information relating to loss experience, claims, classification assignments, and <br />policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your <br />premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting <br />policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, <br />Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and <br />415.778.7272 (fax). <br />Form PN 04 99 01 G (03/19) Printed in U.S.A. <br />Process Date: 12/23/19 Policy E <br />Rime Mattagement DMsion <br />REVIEWED&APPRDVEDBY: <br />'� Risk Management Analyst <br />